S11) Signs and Symptoms of Respiratory Disease Flashcards
What are the six cardinal symptoms of respiratory disease?
- Breathlesness (dyspnoea)
- Cough
- Chest pain
- Wheeze/stridor
- Sputum
- Haemoptysis
Identify 8 other features in a patient’s history which are relevant to respiratory disease
- Childhood illnesses (whooping cough, wheeze, asthma)
- Occupation
- Pets
- Travel
- Smoking
- Medication
- Allergic disorders
- Psychosocial history e.g. anxiety
List four occupations which are particularly associated with lung disease
- Construction worker
- Farmer
- Coalworker
- Silicon and asbestos work
Which six questions can one ask a patient presenting with breathlessness?
- Precipitating factors?
- Timing?
- Effect of position?
- Speed of onset?
- Duration?
- Exercise tolerance? (assess severity)
Distinguish between the presentations of breathlessness in patients with COPD, heart failure and bronchoconstriction
- Patients with bronchoconstriction: “chest tightness”, “increased effort of breathing”, “air hunger”
- Patients with COPD: “”I cannot take a full breath”, “increased effort”, “unsatisfying breathing”
- Patients with heart failure: “air hunger” or “suffocation”
Identify 7 common causes of dyspnoea
- Asthma
- COPD
- Idiopathic pulmonary fibrosis
- Myocardial dysfunction
- Anaemia
- Obesity
- Deconditioning
What are the different types on breathlessness in terms of speed of onset?
- Instantaneous
- Acute (minutes to hours)
- Gradual (days)
- Chronic (months to years)
What are the causes of instantaneous breathlessness?
- Pulmonary embolism
- Pneumothorax
What are the causes of acute breathlessness?
- Asthma
- Pulmonary embolism
- Pneumonia
- LVF/MI
- Hyperventliation syndrome
What are the causes of gradual breathlessness?
- Lobar collapse e.g. lung cancer
- Pleural effusion
What are the causes of chronic breathlessness?
- COPD
- Idiopathic pulmonary fibrosis
- Bronchiectasis
What is the commonest out-patient symptom?
A cough
Which muscles are important for an effective cough?
- Diaphragm
- Major inspiratory muscles
- Major expiratory muscles
- External intercostals
- Glottis
Describe the physiological mechanism leading to a cough
A reflex arc is initated by mechano- and/or chemoreceptors receptors in the:
- Respiratory epithelium
- Oesophagus
- Diaphragm
Why does vocal cord paralysis cause ‘Bovine’ cough?
- A bovine cough is used to describe the non-explosive cough of someone unable to close their glottis
- This occurs in vagus nerve lesions, associated with dysphonia
Identify 6 respiratory causes of a cough and provide and example for each
- Acute infection e.g. bronchopneumonia
- Chronic infection e.g. bronchiectasis
- Nasal/sinus disease e.g. sinusitis
- Airways disease e.g. asthma
- Parenchymal disease e.g. lung cancer
- Pleural disease e.g. pleural effusion
What are the cardiovascular, gastrointestinal and pharmacological causes of a cough?
- CVS: Left ventricular failure
- GI: Gastro-oesophageal reflux
- Drugs: ACE inhibitors, inhaled drugs
Identify 5 causes of chest pain
- Cardiac
- Pericarditis (relieved by leaning forward)
- Oesophageal pain
- Chest wall e.g. costochondritis, rib fracture
- Pleuritic chest pain e.g. pneumothorax, pericarditis
What is a wheeze?
- A wheeze refers to a noisy musical sound produced by turbulent flow through narrow small airways
- It is mostly expiratory
Identify two clinical conditions which often present with a wheeze
- Asthma
- COPD
Describe the common clinical presentation of a wheeze
- Patients often complain of chest tightness
- Nocturnal wheeze
What is the underlying pathophysiology for a wheeze?
- Bronchial smooth muscle contraction
- Oedema
- Mucus production
Why do wheezes occur during expiration?
The positive intrapulmonary pressure during expiration will exacerbate any narrowing of intrathoracic airways
What is stridor?
Stridor describes a coarse inspiratory wheeze caused by extrathoracic upper airways obstruction e.g. epiglottitis, croup aspirated foreign bodies, extrinsic compression
Describe the underlying pathophysiology of stridor
- The negative pressure in the pleural space during inspiration helps to keep the airways open
- The negative pressure in the upper airways caused by inspiratory air flow leads to stridor
When is sputum production increased?
Increased sputum volume is due to allergy, infection or bronchial irritants
How does infected sputum present?
Infected sputum may be green or yellow
Identify some causes of increased sputum production
- Smoking / smoke pollution
- COPD
- Acute bronchitis
- Pneumonia
- Bronchiectasis
Identify 5 causes of haemoptysis
- Infection (most common) e.g. pneumonia, TB
- Lung cancer
- Pulmonary embolism
- Anti coagulation
- LVF
What does cyanosis indicate?
Cyanosis indicates the presence of deoxygenated haemoglobin due to hypoxia
What are some causes of central cyanosis (around lips and tongue)?
- Congenital cardiac disease (right to left shunt)
- Severe heart failure
- Severe respiratory diseases e.g. COPD, severe pneumonia, acute asthma
What are some causes of peripheral cyanosis (feet, hands, ears, nose)?
- All causes of central cyanosis
- Cold exposure
- Raynaud’s disease
What are the main respiratory causes of clubbing?
- Lung cancer (mesothelioma)
- Bronchiectasis
- Cystic fibrosis
- Empyema
- Idiopathic pulmonary fibrosis
When are the accessory inspiratory muscles used?
Accessory inspiratory muscle used if adequate pulmonary ventilation cannot be achieved by normal inspiratory efforts when there is gross overdistension of the lungs:
- Advanced emphysema
- Attack of severe asthma
- Stridor due to laryngeal/ tracheal obstruction
When are the accessory expiratory muscles used?
Accessory expiratory muscles used the elastic recoil of the lungs is insufficient to empty the alveoli or if there is expiratory airway obstruction:
- Some patients with emphysema
- Some cases of chronic bronchitis
- Asthma
How do patients with expiratory obstruction present?
Some patients will stand and grasp a table so that they fix the shoulder girdle and use latissimus dorsi to augment the expiratory effort
Why does pursed lip breathing present in emphysema?
- Pursed lip breathing is a a breathing technique used to control shortness of breath
- It allows pressure to be maintained in the alveoli, preventing their collapse and limiting trapped air to improve ventilation
Why is there barrel chest in emphysema?
Barrel chest occurs due to loss of elastin in the lung allows the chest wall to expand
What is the significance of tracheal position in emphysema?
Tracheal position is used to detect mediastinal displacement
Which conditions cause tracheal deviation away from affected side?
- Tension pneumothorax
- Large pleural effusion
Which conditions cause tracheal deviation towards the affected side?
- Lung/ lobar collapse
- Pulmonary fibrosis (particularly upper lobe)
Describe the underlying pathophysiology of lung/lobar collapse
- Occurs following obstruction of a bronchus
- Gas is resorbed from the lung parenchyma distal to the obstruction
- Lung collapses (volume reduction and negative mass effect)
Which areas on the chest are expected to be dull on percussion in a normal individual?
Due to density of structures:
- Liver
- Heart
- Clavicle
- Sternum
In COPD, why are normal areas of dullness absent?
On percussion, there is decreased hepatic and cardiac dullness due to hyperinflation of the lungs as it pushes the liver down and increases air in the cavity (hyperresonance)
Which lobes of the lungs are best auscultated over the anterior chest?
- Right upper lobes
- Right middle lobes
- Left upper lobes
Which lobes of the lungs are best auscultated over the posterior chest?
- Right lower lobes
- Left lower lobes
What are the three different types of breath sounds?
- Vesicular
- Bronchial
- Tracheal
Describe the location, quality and pitch of tracheal breath sounds
- Location: trachea
- Quality: loud, harsh, hollow
- Pitch: higher
Describe the location, quality and pitch of bronchial breath sounds
- Location: manubrium
- Quality: loud, less harsh, hollow
- Pitch: higher
Describe the location, quality and pitch of vesicular breath sounds
- Location: peripheral lung
- Quality: softer (audible gap between inspiratory & expiratory phase sounds)
- Pitch: low
What is lung consolidation?
- Lung consolidation is a solidification of lung tissue due to the filling of the lungs with liquid and solid material
- These liquids replace the air normally present in alveoli
What is the commonest cause of lung consolidation?
Pneumonia
What pathological processes may lead to consolidation?
Pneumonia – bacterial infection in alveoli produces an inflammatory process and exudate accumulates in alveoli
In lung consolidation, what is heard over the lung fields during ausculation?
Bronchial breathing
Why are bronchial breath sounds heard over an area of pneumonic consolidation?
- If bronchial breath sounds are heard over the chest, it suggests consolidation/fibrosis
- Sounds of bronchial breathing are generated by turbulent air flow in the large airways, and are usually heard over the trachea/manubrium in healthy patients
What are the different types of abnormal breath sounds?
- Discontinuous (non-musical):
I. Crackles
II. Pleural friction rub
- Continuous (musical):
I. Wheezes
II. Stridors
What are the causes of pleural friction rub?
- Pleurisy
- Pulmonary infarction (due to PE)
What are respiratory crackles?
Respiratory crackles are abnormal breath sounds due to the snapping open of airways / fluid in airways)
What are the two types of respiratory crackles and when are they seen?
- Fine crackles – early and fine in idiopathic pulmonary fibrosis, consolidation and LVF
- Coarse crackles – early and coarse in COPD, bronchiectasis (may reduce after coughing)
What are the four possible sounds heard on percussion?
- Resonant → normal finding
- Dull → increased tissue density
- Stony dull → pleural effusion
- Hyperresonant → decreased tissue density
Describe the signs of pleural effusion in terms of:
- Chest radiograph
- Mediastinal shift
- Chest wall movements
- Percussion
- Breath sounds
Describe the signs of pneumothorax in terms of:
- Chest radiograph
- Mediastinal shift
- Chest wall movements
- Percussion
- Breath sounds
Describe the signs of consolidation in terms of:
- Chest radiograph
- Mediastinal shift
- Chest wall movements
- Percussion
- Breath sounds
- Added sounds
Describe the signs of lobar collapse in terms of:
- Chest radiograph
- Mediastinal shift
- Chest wall movements
- Percussion
- Breath sounds
- Added sounds
Which structures in the thorax are well-endowed with pain fibres and which are not?
- Well-endowed: parietal pleura
- Poorly endowed: visceral pleura
What is the significance of pain fibres with reference to how patients experience pain in respiratory conditions?
- Pathology involving the parietal pleura is very sharp, well-localised pain which is worse on inspiration and coughing
- Pathology arising in the lung itself is diffused and poorly-localised pain
Why does the trachea shift in tension pneumothorax?
Increased pressure of air in the pleural space pushes the trachea away from the lesion
In 4 steps, explain why hypotension often presents with tension pneumothorax
⇒ Pushed mediastinum obstructs great vessels in lung hilum
⇒ Decreased venous return from the pulmonary artery
⇒ Decreased cardiac output
⇒ Hypotension
